The
majority of athletes recover from a concussion within 10 days, however, at
least 10% of athletes continue to have signs and symptoms (s/s) beyond 14 days.
Post-concussion syndrome (PCS) occurs when patients display persistent s/s
beyond normal recovery period (> 14
days). This systematic review found 564 studies that fulfilled their search
criteria and utilized 119 articles that focused on pathophysiology, diagnosis,
and treatment/rehabilitation of concussions and PCS. Acceleration-deceleration
forces are the most common mechanisms that strain the neuron by causing the
brain to move within the skull. The stretch of the neuron results in a
neurometabolic cascade that causes an array of problems (e.g., hyperglycolosis, mitochondrial dysfunction,
decreased blood flow) within neuronal tissue, which can last for 7-10 days.
Researchers have described this period of time as a window of vulnerability
that a second insult prior to healing could lead to a more severe injury. Magnetic
resonance spectroscopy (MRS) can determine the concentration of
brain metabolites such as lactate, which can characterize the state of the
central nervous system. MRS imaging studies have shown that even after s/s
subsided there is still an ionic imbalance (e.g., levels of calcium, sodium,
and potassium are not within homeostatic levels in the neuronal cells) leaving
the brain vulnerable for a secondary injury. Depression and migraine
differential diagnosis is also important to evaluate because of the overlapping
s/s. This review also notes that researchers found other physiological changes
that can occur following a concussion are increased heart rate, autonomic
dysfunction, and cerebral infarction, which can be exacerbated with exercise.

The differential diagnosis of
PCS include depression, somatization, chronic
fatigue, visual dysfunction, or a combination of these illnesses. The challenge
is to determine whether the prolonged s/s implicate a concussion pathology or
one of these secondary processes (e.g., migraine, depression). Initial
concussion assessment should include concentration exam (e.g., counting down
from 100 in 3’s), memory recall, cranial nerve exam, and vestibular-ocular exam
including balance testing. An exertion test can help determine a concussion
from psychological illness. If s/s occur during exertion but are alleviated
with rest it is likely a concussion, however, if s/s are not relieved with rest
it could indicate a psychological disorder. Another more broad definition used
to define PCS is having 3 or more of the following s/s: headache, dizziness,
fatigue, irritability, insomnia, difficulty concentrating, or memory
difficulty. After diagnosis the clinician should provide treatment and
rehabilitation for the concussion or PCS. There still is no therapeutic agent
to accelerate recovery. Treatment includes primarily rest, however some
therapeutic agents can be utilized. The most commonly prescribed medications
for PCS are antidepressants. These therapeutic agents block serotonin from
being taken up and can improve depression symptoms and cognition. In addition,
glutamate blockers such as NMDA antagonists are used to help alleviate
concussion s/s by preventing or limiting the ionic imbalance. Rest is
necessary, however, prolonged rest especially for athletes can lead to physical
deconditioning, metabolic disturbances, fatigue, and depression so implementing
a gradual return to play after the concussive s/s have dissipated should be
executed. Rehabilitation includes a gradual return to play. That is, starting
when the athlete has been s/s free they can begin a treadmill test. If s/s
develop during or following the treadmill test patients must return to the
previous phase, and if no s/s are experienced patients progress through each of
the phases of the return to play criteria. In children it has also been
suggested that an information booklet on strategies for dealing with concussion
s/s resulted in less behavioral changes and s/s. Other rehabilitation
techniques include a neurocognitive portion that uses cognitive tasks to improve
aspects of cognition such as attention, memory, and executive functioning. What
have you done for athletes with prolonged s/s of concussions? Have any of your
athletes developed an illness due to a prolonged concussion?

8
comments:

I have been conducting neuropsychological testing for 2 years and I am heading back to school for my PsyD to work with athletes with concussions. I have not tried anything with other patients but I had a very prolonged response to my initial concussion and numerous followed in a short time due to my vestibulopathy and vertigo. After about 8 months I began biofeedback/neurofeedback treatement. It was incredible the healing the occurred shortly after I began this treatment. It's still fairly new for use of concussions but it seems promising!

ssand15-Thank you for sharing! How many treatments did it take for some of the s/s to begin to subside. Can you share a little more detail about what your biofeedback/neurofeedback treatments consisted of.

We just had a meeting re vestibular therapy and PCS yesterday. One of the topics brought up was does cocoon treatment perhaps have something to do with vestibular issues because of the lack of feedback to the system secondary to the amount of rest involved. Thoughts?

Cocoon treatment is a term some of the docs have been using for dark room, stay in bed, no tv, texting, computer, etc. The local newspaper ran an article about concussions a few years ago and called it cocoon therapy. some of the docs have been using it. We were discussing in a vestibular talk last week if overdoing that could lead to some prolonged vestibular issues. Wondering your thoughts. Thanks

Okay thank you! Cocoon treatment is basically what I have been calling cognitive rest. I believe that it does relate to the vestibular-ocular system. Moving your head and eyes up/down and side to side are those motions we do to read, text, or work on the computer. That head-eye movement can increase concussive sign and symptoms thus prolong recovery if not rested.

We've definitely not tried anything together with different affected individuals but I had an exceptionally long term reaction to our initial concussion along with several put into practice in a short time on account of our vestibulopathy along with vertigo.

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